Emergency Information Form

FOR LIFE THREATENING EMERGENCIES: CALL 911

FAMILY NAME: _____________________________________________________

CHILDREN'S NAMES:

______________________________________________AGE:_______________

______________________________________________AGE:_______________

______________________________________________AGE:_______________

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FAMILY ADDRESS:_________________________________________________

NEAREST CROSS STREETS:_________________________________________

NUMBER TO CONTACT PARENTS:_____________________________________

DOCTOR'S NAME:__________________________PHONE:__________________

HOSPITAL:_________________________________PHONE:_________________

POISON CONTROL CENTER (in Louisiana): 1 (800) 256-9822 ___________________
(look up your area's number)

NON-EMERGENCY NUMBERS

POLICE/SHERIFF:_______________________PHONE:_____________________ _____

FIRE DEPARTMENT:____________________PHONE:__________________________

MEDICAL SERVICES:___________________PHONE:__________________________

NEIGHBOR TO CONTACT FOR HELP:___________________________________

NEIGHBOR PHONE NUMBER:_________________________________________

ADDITIONAL INSTRUCTIONS:____________________________________________

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